HomeMy WebLinkAboutWaldorf JUDITH T. TERRY `R ', < Town Hall, 53095 Main Road
TOWN CLERK .. �t � • P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �' Southold, New York 11971
MARRIAGE OFFICER 1 t' � � Fax (516) 765-1823
® $ Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1780-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WALDORF, PETER
Mailing Address 1 AMERICAN EMBASSY OFFICE
Mailing Address 2 USBER, BOX E
City St Zip APO NY 09742-0000
Property Address 1 855 SKUNK LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-298-8000
Tax Map No. section 97.00 block 4 lot 5.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/08/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �F �CQ
FO ��
Town of Southold �� -F- Application No. 7 7 71
Judith T. Terry, Town Clerk ,, : ; �►
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 y' zt' `" "'� ' $25.00 - Non-Residential
Southold, New York 11971 Oho. �O�'1.• �
Telephone .� '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: fok4' td Pd
OWNER MAILING ADDRESS: 4111er/C' Fi01hiiSs Q i'c
U� e• jj 0 N opco—
OWNER PROPERTY ADDRESS: 6:76-5--- 57Zup � �"d'•�
OWNER TELEPHONE NUMBER: G(n `tr&z, � z:� d �- Foo 6
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TAX MAP NO. : Section 97 Block 7 Lot
CROSS STREET: 0 £ (
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool C/ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
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Signature of Appli
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" RECEIVED BY:
Town Clerk's Office
DATE:
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